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Saturday, February 29, 2020

Good vs Bad Pain: Very Important Lesson to Learn when You Are Injured

Dilemma of Good vs Bad Pain

For the athlete dealing with a painful situation, coming to a useful understanding of what is good and bad pain becomes crucial to speedy rehabilitation. Good pain is discomfort that is appropriate to work through, or to feel afterwards. Bad pain is discomfort that must be stopped; it is the breeding ground for setbacks and flare-ups.
Varying pain thresholds in athletes can greatly complicate matters. Some athletes with a high pain threshold can train through a more serious injury believing that they are doing no harm, only to find that the injury has greatly worsened. In this case, their body’s own feedback mechanisms have let them down. Something in their head is yelling: “No pain, no gain!” and probably in several languages. They can participate at very high levels with pain, hoping they can work through it. Sometimes they can, but many times they cannot, and the injury gets worse. Most of these athletes need the outside help of coaches and personal trainers, doctors and physical therapists, to help set some limits. Their own “self-preservation” mechanism is not working properly. Evolution to better body awareness can occur with good coaching. There is hope for this group. For other athletes, including myself, with low pain thresholds, all pain is bad and cannot be tolerated. This group may actually learn to accept some pain as okay. They can also evolve.

Besides varying pain thresholds, there are many physiological reasons that the exact same injury can hurt a lot more for one athlete than another. The closer the injury is to a nerve, the more it hurts. The more your body swells with any injury, the more you hurt, especially with deep swelling that cannot escape the joints, bones, ligaments, or tendons. If the injury is on the outside of your foot, and you walk/run on the outside of your foot, you will hurt more than another patient who walks/runs on the inside or the middle of their foot. The weaker the area is before you are injured, the more you will hurt after the injury, since it will take longer to get the area strong. These factors are just a few.

Remember, injuries first heal, and then double heal. Some bones, like your metatarsals, may get approximately twice as thick during the total healing process. This is why tendon and ligament injuries can heal with scar tissue that leaves the tissue twice as thick. So, even when an injury is completely healed, more healing may occur for several more months, possibly producing noticeable symptoms to the athlete. Healing always produces some level of pain with swelling, muscle tightness for protection, scar tissue breakdown, etc. This can be good pain. So, how do we make some sense of this?

Four Golden Foot Rules that may give us some focus:
Golden Rule of Foot: Never push through pain that is sharp and produces limping.
Golden Rule of Foot: Never mask pain with pre-activity drugs, including ibuprofen,
                                         aspirin, etc., and even icing.
Golden Rule of Foot: 80% of healing occurs in 20% of the overall time, with the
                                    remaining 20% taking 80% of the total time.
Golden Rule of Foot: Good pain normally dwells in the 0 to 2 pain level (scale 0 to 10).

Let us focus on these four rules. When an athlete asks if they can participate in their activity, there is no breaking of the rule of sharp pain and limping. Good pain may be at the start of a workout, then eases up. If the pain comes back in the middle of a workout, this is bad pain (as you have hit the threshold of tissue strength) and it is best to stop. Participating in a team activity that is semi-dependent on you is tough as you ease yourself back into activity. But you must be clear from the start of the activity that you may need to stop if pain develops. Ask your co-participants to tell you if you are limping. Sometimes they see it before you feel it. Limping throws the entire body off, risking other injuries. Sharp pain normally produces limping, but limping can also occur as you transfer weight to avoid pain or if a body part is too stiff to bend properly.

Drugs, as simple as aspirin, ibuprofen, etc., can mask little to significant pain. Never take these drugs before participation, only after, if allowed. In general, taking medication six hours before an event is permitted. Many of the anti-inflammatory drugs (NSAIDs) also inhibit bone healing, so are contra-indicated in bone injuries entirely.

Healing can take a long time to completely occur with any injury. The job of the doctor, therapist, and patient is to try not to repeatedly get in the way of the healing process. But even with our best efforts, we tend to take two steps forward, one step back, then two forward, then three back, and so on. I am happy to say in following injuries for more years than most of my readers have existed on this earth, injuries do heal. People do forget what ankle they sprained in 2004, and what heel got plantar fasciitis in 2007. Yet, most healing occurs in 20% of the time, with the remaining 10-20% healing occurring in 80% of the time. When you are 80% better, level 1 or 2 pain may still exist, but you can do everything athletically your heart desires. But, it can take months and months of icing, stretching, strengthening, and occasional flare-ups, to get rid of the last 20% of symptoms. It is considered the realm of good pain, but it can wear thin on our nerves and patience.

Good pain is pain/discomfort/soreness/tenderness/dolor that does not have to interfere with activity. Listen to your body. Does the pain cause limping? Is the pain sharp in intensity? Does the pain come on in the middle of an activity? Does the pain come on after an activity and then hurt for several days? Does the pain come with increased swelling? These are all signs of bad pain. Good pain stays in the 0 to 2 range, no matter what your pain threshold is. Good pain is normally gone the next day, so there are no residuals. Good pain does not cause limping, and is not sharp, although a temporary sharp twinge lasting seconds is typically okay. Dealing with good pain is not the perfect scenario for my patients, but it is your daily reminder to keep icing, stretching, strengthening, and listening to your body. Good pain can be a good guide to allow you to work an injury to complete healing. It can be your training guide and friend.
But, you may ask, why not just wait until you have no pain before you go back to activity? The more inactivity, the more de-conditioned you become, and the longer the return to activity process will actually take. So, it is better to try to discover the difference between good and bad pain. The better you become, the better decisions you will make in your athletic life, and the longer you will be an athlete. The better you become, the better prepared you will be for the next injury. An important medical decision may be made based on your knowledge of good and bad pain. If all pain is bad, you will have a less active life and may seek surgical intervention as a quick and sometimes unnecessary fix. If you still believe “No pain, no gain,” I cannot wait to see you at our sports medicine clinic as a regular customer, but I will try to convince you otherwise in the long run. Learn about your body through this process. It has prevented three surgeries for me. And the same rules can apply to anyone recovering from any type of injury, not just athletic injuries. Good Luck!!

This is an excerpt from my book "Secrets to Keep Moving: A Guide from a Podiatrist"

3 comments:

  1. Dr. Blake, I love the term double healing of an injury! I will be using this term in my clinic Monday. I already adhere to your Golden Rules. Thanks for being a lifelong educator and mentor to those of us that want to continue to improve as healers for our patients.

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  2. Rich, agree with your observation. Being a hard headed Irishman, I have at times ignored the advice of true rest and rehabilitation. Three years ago, I sustained a anterior rotator cuff rupture because I didn’t listen to my body. Still have not returned to swimming.

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Thank you very much for leaving a comment. Due to my time restraints, some comments may not be answered.I will answer questions that I feel will help the community as a whole.. I can only answer medical questions in a general form. No specific answers can be given. Please consult a podiatrist, therapist, orthopedist, or sports medicine physician in your area for specific questions.